DISPATCHESMSF CANADA MAGAZINE Volume 23 Edition 1 Spring 2019

MEDICAL CARE IN ACTION: Highlights from MSF’s lifesaving work around the world.HUMANITARIAN INNOVATION: Developing the tools we need to respond to new emergencies. CANADIANS ON MISSION: Helping MSF deliver care in Democratic Republic of Congo.

ALSO INSIDE:

doctorswithoutborders.ca

Women’s health in crisis zonesHumanitarian emergencies can often create unique and urgent medical needs for women — how should MSF respond?

In the small town of Pulka, in north-eastern Nigeria, Doctors Without Borders/Médecins Sans Frontières

(MSF) has been providing care for thou-sands of people displaced by ongoing conflict between government forces and non-state armed groups.

Unarmed people fleeing the con-flict’s brutal violence have sought shelter in Pulka’s increasingly crowd-ed displacement camps. MSF doc-tors, nurses, psychologists and other specialists are on the ground, work-ing to provide critical care to people who have often arrived in desperate conditions – some malnourished and many others traumatized by their re-cent experiences.

Amid this medical activity, our teams in Pulka have also developed an-other important tool: briquettes. An MSF innovation unit came up with an alternate fuel source that people in the camps can use to cook their food. By converting available ma-terials such as sugarcane peels into briquettes, it is possible to generate heat without firewood.

But why should an emergency medical organization like MSF spend valuable time and resources on something like alternative cooking fuels in the middle of a humanitarian emergency?

Most of the people in the Pulka dis-placement camps are women and small children. These women are often the sole caregivers for their families. What food they receive from aid agencies cannot be eaten without being cooked, and to do that they need firewood. The only place to find firewood is beyond the camp’s guarded perimeter. But it is while searching for firewood outside the camp gates that women are most at risk of sexual violence.

“MSF treats a large number of patients — women and children in particular — who have been raped, sexually assaulted or otherwise attacked on these [firewood] outings,” says an MSF report on the briquettes project. “These problems are present in several other emergencies.”

In Pulka, as in many of the other plac-es where MSF works, peoples’ needs are high, and cut across demographic lines. But, also like many of the other places where MSF works, the risks faced by women are specific and par-ticularly troubling.

EXTREMELY VULNERABLE “Most people living in the camps are women,” says Altine, the midwife super-visor at MSF’s hospital in Pulka. “The ma-jority of our patients have gynecological complications, mostly aged between 12 and 18 years. Patients tell us they were abducted, forcefully married, sexually as-saulted or suffered some kind of violence. They often carry the added burden of psy-chological trauma, and we also treat cases of sexually transmitted diseases.”

For years, people in northern Nigeria have faced hardship and violence. They have been exposed to disease outbreaks, and lack access to health services. I over-saw MSF’s operations there between 2010-12, and saw first-hand how cycles of violence left people – especially wom-en and children — extremely vulnerable.

MSF is a humanitarian medical organiza-tion. Our job is to deliver essential care wherever it is most urgently needed around the world. Impartiality is one of our core values, which means we treat anyone who needs our help most — re-gardless of age, religion, ethnicity, gen-der or any other marker of identity. But as the above story from Nigeria suggests, in humanitarian crises, it is often women

who bear the brunt of the suffering. In such situations, a women-centred medi-cal response is not a violation of our prin-ciples; it is the essence of impartiality.

In this issue of Dispatches, we focus on the many ways that MSF’s medical in-terventions must take into account the reality of women’s health needs on the front lines of the world’s emergencies — from maternal-health complications and sexual violence to unique mental-health challenges. As a humanitarian organization, we seek to alleviate the suffering of people affected by conflict, disaster, disease and neglect. All too frequently, the impact of these crises falls disproportionately on women and children, and so we will continue to calibrate our medical response to meet their needs.

Thank you for being a part of our hu-manitarian efforts. Without you, we would not be able to deliver assistance to those who need it most. With your backing, we remain relentlessly com-mitted to finding ways to provide hope, dignity and medical care to the world’s most vulnerable people, whoever and wherever they may be.

Joseph BelliveauExecutive director, MSF Canada

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FROM THE EXECUTIVE DIRECTOR

AT ADDITIONAL RISKA DISPROPORTIONATE NUMBER OF MSF’S PATIENTS ARE WOMEN, WHO FAR TOO OFTEN BEAR THE BRUNT OF SUFFERING IN PLACES AFFECTED BY CRISIS

IN THIS ISSUE...COVER STORY: WOMEN’S HEALTH How MSF responds to the needs of our biggest group of patients .................. p. 04

Maternal health: Difficult deliveries in a Rohingya refugee camp; treating obstetric fistula in Nigeria; a Canadian midwife in Democratic Republic of Congo .......... p. 06

Mental health: support for survivors of trauma in Honduras .......................... p. 09

Sexual violence: Conflict and urgent needs in Central African Republic ................p. 10

Access to care: Giving women in Niger a safe space to seek treatment ...........p. 11

SUPPORTER STORIES Donor FAQ: Why monthly giving matters ....................................p. 12

HUMANITARIAN INNOVATION How MSF is making a transformational investment in new ways to deliver humanitarian medical care ................p. 13

CANADIANS ON MISSION A Montreal accountant sees MSF’s impact in Democratic Republic of Congo .......p. 14

www.doctorswithoutborders.ca

Doctors Without Borders/ Médecins Sans Frontières (MSF) 551 Adelaide Street West Toronto, Ontario, M5V 0N8 Tel: 416-964-0619 Fax: 416-963-8707 Toll free: 1-800-982-7903 Email: dispatches@msf.ca

Donor relations: donorrelations@msf.ca; 1-800-928-8685

Cover photo: Rohingya refugee Um Kalsoum with her son Abdul at an MSF clinic in Cox’s Bazar, Bangladesh. ©Mohammad Ghannam/MSF

Circulation: 150,000 Layout: Tenzing Communications Inc. Printing: Warren’s Waterless Printing Spring 2019

ISSN 1484-9372

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Since the beginning of 2019, the escalation of violence in north-ern Burkina Faso has resulted in dozens of deaths and the internal displacement of thousands of peo-ple who urgently need help. People have fled from their homes, unable to take anything with them. Many have arrived at the nearby villages of Foubé, Barsalogho, Arbinda, Kelbo and Déou. In Barsalogho camp, fami-lies live in tents and access to water remains a problem. Doctors Without Borders/Médecins Sans Frontières (MSF) is working to minimize the risk of an epidemic; more than 2,100 chil-dren were vaccinated against measles in Foubé during the first day of a cam-paign aimed at vaccinating 7,000 chil-dren. Another 600 were vaccinated in Barsalogho. However, the needs are still significant, according to Idrissa Compaoré, MSF’s medical coordina-tor in Burkina Faso, who highlighted a lack of access to clean drinking water.

MSF teams in Libya have observed a sharp increase in the number of people held in detention centres fol-lowing a series of disembarkations of people to Libyan shores. Vulnerable refugees, migrants and asylum seek-ers were intercepted at sea and brought back to Libya in violation of international law. MSF teams orga-nized medical referrals to a nearby hospital. Among the people recently

disembarked, some were suffering from malnutrition, hypothermia or se-vere diarrhea. Some report that before trying to cross the Mediterranean Sea, they had been held captive by traf-fickers for weeks, sometimes months, and were systematically abused and tortured. Detained migrants in Libya have virtually no access to open air space and little access to clean water and food — which is of particular con-cern for people with serious medical conditions, as well as for small chil-dren and pregnant women.

MSF is dismayed by several find-ings of the team appointed by the Saudi and Emirati-led Coalition (SELC) to investigate the bombing of an MSF cholera treatment centre (CTC) in Yemen in 2018. We demand that the results of the investigation be reviewed and false allegations against MSF be withdrawn. While the report recogniz-es that the SELC was partly responsible for the bombing, it also claims MSF did not take the appropriate measures to prevent the attack. The report claims that MSF failed to display a distinc-tive emblem on the facility and did not explicitly request that the facility be placed on a no-strike list. In fact, the compound containing the CTC had three distinctive logos displayed, while MSF shared its location at least 12 times in writing with the correct co-alition authorities.

MEDICAL CARE IN ACTION

MSF AROUND THE WORLD

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An MSF nurse tests a patient for malaria at the Barsalogho displacement camp in Burkina Faso.

DISPATCHESDispatches is published twice annually and distributed to supporters of Doctors Without Borders/Médecins Sans Frontières (MSF) Canada.

This magazine is printed on recycled paper using a waterless process to reduce environmental impact.

Dispatches is also available as a digital magazine. If you would prefer to receive Dispatches electronically, please email dispatches@msf.ca.

Several years ago, I was part of a Doctors Without Borders/Méde-cins Sans Frontières (MSF) team

in northern Democratic Republic of Congo (DRC). One day, we visited a threadbare local hospital. As I entered the facility, I saw a body lying on the floor, covered by a blanket.

“Did someone die?” I asked.

“Yes,” I was told. “That is a young woman who died giving birth.”

I never learned the young woman’s name, but I’ve never forgotten her. I knew that health facilities in that area

were desperately short of resources and trained health personnel. I knew that many women around the world don’t have the power to make crucial decisions, such as whether or not to spend money to hire a vehicle to get themselves to the nearest hospital, even when they desperately need to go. And I knew the statistic that tells us that some 800 women die due to pregnancy-related causes every day. But I also knew it did not have to be that way. And seeing her lying there, like an afterthought, hit me hard.

It also made me angry. As a nurse, see-ing a woman die needlessly because

she could not access medical care made me want to shout from the roof-tops. That was years ago, but I’m still angry about it now, because deaths like these are happening with horrify-ing frequency to this day — and they can be prevented.

HIGH RATES OF MORTALITY

There has been progress in the realm of women’s health, including a signifi-cant drop in maternal mortality world-wide. But in many countries where MSF works, a shocking number of women are still being lost.

According to the World Health Orga-nization, more than 50 times as many women die in childbirth in Afghani-stan as they do in Canada. Maternal mortality rates are 176 times higher in Central African Republic than in Japan, and 214 times higher in Chad than in Sweden.

MSF’s core purpose is to provide life-saving medical care to those who can-not otherwise access it. While we are not specifically a women’s healthcare organization, most of our patients are women and children. In project after project, I’ve seen our waiting rooms and wards full of pregnant women, women who’ve been injured or fallen ill, and women with their children. I’ve seen the lengths women will go to in order to care for their children.

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BEARING AN EXTRA BURDENMSF is not just a women’s health organization, writes Meinie Nicolai, but our biggest group of Patients faces distinct and sometimes deadly risks

COVER STORY: WOMEN’S HEALTH

LAST YEAR, MSF’S HUMANITARIAN MEDICAL CARE INCLUDED:

18,800 PATIENTS TREATED MEDICALLY FOR SEXUAL VIOLENCE

288,900 BIRTHS ASSISTED, INCLUDING CAESAREAN SECTIONS

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These are remarkably strong women and they are anything but victims. Many perform backbreaking labour in addition to running their households and caring for their children and other family members. Yet in spite of the huge burdens they shoulder, they rarely pos-sess the power to decide when they themselves can get lifesaving care.

Put simply, women have distinct health risks that men do not have, and these risks must be attended to. Let’s start with the obvious: women get preg-nant and bear children. Worldwide, more than a third of all deliveries have complications, including some condi-tions likely to kill women if they cannot access emergency care.

The challenges women contend with go beyond childbirth, of course. Con-flict creates environments of rampant

exploitation of women and girls, and of rape used as a weapon. Displace-ment in general leaves women and girls more vulnerable to sexual vio-lence and trafficking.

ACCESS TO ESSENTIAL CARE

MSF tries to help as many people as we can; more often than we’d like, we are the only medical organization in the places where we work. Last year, we assisted with 288,900 births, and medically treated 18,800 survivors of sexual violence.

As an organization, we look forward to the day when women the world over have access to the kind of medi-cal care many of us in the developed world take for granted; to a future where no girl or woman has to die because she could not reach a hospi-

tal in time; and to the day when any of us can be confident of entering a remote rural hospital without seeing the body, shrouded on the floor, of a woman lost in childbirth.

The women who seek our care will not be afterthoughts. They cannot be, be-cause tomorrow needs them.

Meinie NicolaiFormer president, MSF Belgium

A longer version of this essay was origi-nally published as the introduction to Tomorrow Needs Her, a collection of first-hand accounts by MSF field work-ers about responding to women’s health needs around the world. To read these stories and to learn more, please visit womenshealth.msf.org.

A dazed woman sits on a green hospital bed. She looks as if she has just run a marathon, but with

none of the euphoria. She has just giv-en birth to a 4.1 kilogram (9 pound) boy – a record weight for this delivery room. A midwife places the newborn baby in her arms and she puts the child to her breast.

The woman is a patient at Doctors Without Borders/Médecins Sans Fron-tières (MSF)’s Kutupalong hospital in Cox’s Bazar, Bangladesh, just across the road from what is now the biggest refugee encampment in the world. Since late 2017, Cox’s Bazar has been home to close to one million refugees, members of Myanmar’s Rohingya eth-nic minority — most of whom crossed the border into Bangladesh within a matter of weeks following a brutal campaign of targeted violence against them in their home country. Now they remain trapped in overcrowded condi-tions on a small spit of land between

the two countries, unable to move freely into Bangladesh or to return safely to Myanmar.

The young woman on the bed is in the minority in opting to give birth at a hospital, as it is thought that about four in five Rohingya women in Kutu-palong currently give birth at home.

“Usually, I’m a big fan of home deliv-eries,” says Yvette, who manages ac-tivities in the MSF hospital’s maternity ward and comes from the U.S. north-west. “But in this case, conditions at home are not ideal.”

That’s because home for most of the refugees in Kutupalong, as well as the

LIMITED OPTIONSPregnant women and new mothers living in Bangladesh’s overcrowded camps for Rohingya refugees face many health risks but have nowhere else to go

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WOMEN’S HEALTH: MATERNITY

MSF’S ROHINGYA RESPONSE:*

1,050,000 MEDICAL CONSULTATIONS FOR ROHINGYA REFUGEES IN BANGLADESH SINCE AUGUST 2017

49,401 MENTAL HEALTH CONSULTATIONS

4,885 PATIENTS TREATED FOR MEASLES

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Onyeka Martins Madueke is a Doctors Without Borders/Médecins Sans

Frontières (MSF) field administrator

from Anambra State in Nigeria. He wrote the following blog post about MSF’s obstetric fistula clinic in Jahun, northern Nigeria:

As I watch the women celebrating their final discharge from the MSF fis-tula clinic here in Jahun, the radiant look on their faces is contagious, and all of us who are here to celebrate with them know why.

Fistula is a devastating injury which is almost always sustained in childbirth, after an obstructed labour. This hap-pens when the delivery of the baby has stopped – often because the ba-by’s head is too big to pass through the mother’s pelvis.

Without an emergency caesarean, the baby’s head can press against the wall of the birth canal, causing a hole or “fistula” to form, connecting the vagina with the bladder or rectum.

Months ago, following an improperly conducted or complicated delivery, these women woke to realize that their bodies had no control over urine discharge (in cases of vesico-vaginal fistula) or fecal discharge (in cases of recto-vaginal fistula).

These fluids passed from the bladder or rectum, through the fistula, and leaked constantly through their vagi-nas. Consequently, the women need-ed to employ rags or towels to absorb them. People often consider the smell repulsive or embarrassing, and the

women may have been excluded from their communities as a result.

Today, however, is different from those days, and the women at this celebra-tion have found their pride again after they thought they had lost it.

Almost all the patients who get ad-mitted into the fistula ward are reg-istered as married women. After a while, however, a number of them lose their marriages. Their husbands file for divorce while the women are still receiving treatment in hospital.

At this point, they can start to feel re-ally unwanted; depression begins to sink in, and they begin to believe that everything is wrong with them – may-be a curse, or something worse. This usually marks the beginning of a wor-rying psychological state, which en-dangers a patient’s speedy recovery.

The MSF clinic staff become like fam-ily to these patients, and are often the reason most of them do not give up. At first, not many of them are convinced that they will one day regain the abil-ity to control the discharge of urine or fecal matter, but eventually it happens.

This is often a life-transforming experi-ence for them. Today, these discharged patients will travel back to their various homes with greater confidence than they entered the ward with.

As I write, I think of how much it takes for MSF to bring so much care to the people here free of cost, and I feel strong emotions welling up in me. If I do not stop now, I may end up flood-ing my laptop keys with tears of joy.

To read more of Martins’ blog, visit blogs.msf.org/bloggers/onyeka-martins-madueke.

Obstetric fistula: restoring dignity and health in Nigeria

other makeshift camps in Cox’s Bazar, is a hut with an earth floor and a tarp roof. Water has to be hauled from the nearest pump, and the communal la-trines are often overflowing. “It’s not a nice place to live, let alone to labour and deliver in,” says Yvette.

For those women delivering at home, options are limited if something goes wrong. At night the camps are unlit and the steep, narrow paths are slip-pery underfoot. Precarious bridges pass high across swamps and muddy streams. With few roads in the con-gested camps, an ambulance ride involves perching on a plastic chair strapped to two bamboo poles.

CRITICAL CASES

And so women with complications in labour usually stay where they are at night. “By the next day, often they are in really rough shape,” say Yvette. Or they may bleed at home for days and then arrive at the clinic with sepsis.

Uncomplicated births are the excep-tion in Kutupalong hospital, rather than the rule. “It’s rare that we see a normal delivery here,” says Yvette. “Generally I only see critical cases – this feels more like an emergency room than a normal delivery room.”

BORN INTO AN UNCERTAIN FUTURE

Statistically, of the 10 beds currently occupied in the maternity ward, five women are here because of medical emergencies – eclampsia, post-par-tum hemorrhage, sepsis. Four women are here because they were raped. Just one of these 10 women is likely to have a normal delivery.

Since last year, the births of Rohingya babies in Bangladesh have not been registered. The Rohingya children born here will have no birth certificates, no refugee status and no citizenship.

“In other countries where I’ve worked with MSF, women in the maternity ward visit with those in neighbour-ing beds, but not so much here,” says Yvette. “Here they keep to themselves, cover their heads or faces with scarves and are unusually quiet.”

‘Can you examine this woman for me? Something feels strange,” one of the nurses called over to

me. “This is her 12th delivery at term, all normal vaginal births. Seven are alive, four died but not as newborns. No cae-sareans. Last birth was two years ago.”

I palpated the woman’s abdomen, confirming that the baby felt a normal size and position. I pulled on a ster-ile glove and reached in to check the opening of the cervix. The head was high, the cervix not fully open. Then I felt something abnormal, my fingers stroking a slippery little circular tube, beating against my fingertips.

“Cas Rouge!” I called out. “Cord Prolapse!”

When a woman has delivered many ba-bies, the uterus remains more relaxed, more floppy. It increases the risk that the baby’s head won’t jam tight against the birth canal, allowing the umbilical cord to slip below the head. Then, as the baby descends head-first down the passage, the cord can get squished,

cutting off vital oxygen and nutrients — resulting in compromise or even the death of the baby.

The team sprang into action while I re-mained in position, my hand pushing up hard against the baby’s head, re-lieving pressure off the umbilical cord.Tresor, the local staff supervisor, called on the radio to quickly prepare for a caesarean section.

I had discovered the hard way that if I ran alongside a stretcher, the operat-ing room door was too narrow to al-low me to pass through the door be-side it. So I knew the only way I could keep continuous pressure against the baby’s head, preventing loss of blood flow through the umbilical cord, was to jump up onto the stretcher and kneel behind the patient. With the side

rails of the gurney locked into position, we took off!

Once in the operating room, I crouched beside the table, noting that I could feel the umbilical cord beat-ing against my fingers, reassuring me that the baby was alive. But the pulse at less than 110 was a worrying sign. I felt a movement against my hand: the surgeon’s own hand brushing past my fingers as he reached down to cup the baby’s head and lift it up and out of the pelvis.

SMALL SIGNS OF LIFE

The baby was brought limp and si-lent to the warmer. Seconds ticked by, but I was aware of how long the baby was taking to get a good breath of air. “Guedel!” I called out, grasping the small tube to insert into the baby’s mouth to open his airway.

I slipped in the tube, replaced the mask and puffed gently. Within a min-ute the baby boy was making gasping

efforts and, by the second minute of assisting his breathing, he broke the si-lence with the most beautiful sound in the world — a lusty cry!

As we continued to monitor the baby and provide routine care, I looked around the operating room, noting that the ambience was light and easy now that the newborn had recovered and the mother was doing well.

“That was a sight to behold,” comment-ed Dr. Juan Diaz, the MSF surgeon, as he began to remove the drapes. “I heard the call for surgery and ran into the room — smack into the butt of a mid-wife kneeling on the gurney!” I giggled along with the team, thinking to myself: “Note to self. Next time build a wider operating room door!”

To read more of Lanice’s blog, visit blogs.msf.org/bloggers/lanice-jones.

WOMEN’S HEALTH: MATERNITY

Dr. Lanice Jones is a physician from Canmore, Alberta. She recently took on the role of midwife at a Doctors Without Borders/Médecins Sans Frontières (MSF) medical project in Mweso, Democratic Republic of Congo (DRC). The following is an excerpt from the blog she kept during the experience:

RUSH DELIVERYA Canadian midwife and her msf colleagues act quickly to save a newborn’s life in democratic republic of congo

Dr. Lanice Jones, right, with new mother and baby.

‘Cas rouge!’ I calledout. ‘cord prolapse!’

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The sky over the La López clinic in Choloma, Honduras, is clearing after torrential rains as Doctors

Without Borders/Médecins Sans Fron-tières (MSF) psychologist Ámbar As-saf gazes out through the bars of the heavy iron gate to the street beyond.

“People here are deeply affected by violence, especially women,” she says. “The patients I see are mostly young women between 15 and 35 years old. ... Physical violence, psychological vio-lence and sexual violence are extremely common. I see a lot of women who suffer from depression because they’ve experienced violence and normalized it as a defence mechanism.”

Assaf and her team work with patients to help them process their experiences and regain some semblance of control over their lives. But the pervasiveness and intensity of the violence in Cholo-ma can leave deep scars.

“One of the cases I remember most was a family,” says Assaf. “A pregnant

woman with two kids, one six years old and one eight. One day the hus-band didn’t come home. He was killed in a hit, strangled, and the body was in really bad shape. The kids saw ev-erything. You see cases like this all the time here.”

IMPOSSIBLE CHOICES

The family moved to another town two hours away, joining the ranks of the thousands who have become internally displaced in Honduras. But even with the move, they still don’t feel safe, says Assaf, and being forced to leave the city has also cut them off from social networks and economic opportunities.

“The mother will give birth in one month. And she’s considering re-turning to Choloma, because there are no jobs in the town where they fled,” she says.

The MSF outreach team worked with the children to provide emotional sup-

port and build coping mechanisms as they mourned the loss of their father.

But the family is still faced with an im-possible choice, one familiar to many people in Honduras: stay and risk your life at home, or risk your life on the move, gambling on a better future.

“There are so many needs in this area,” says Assaf, who lives in nearby San Pedro Sula. “The more we work, the more needs we see. We’ve all seen people killed in the streets. We can’t change the situation here, but we can support people who have to live with the violence.”

Crime is both endemic and rampant in Choloma, and women and girls are of-ten most at risk. MSF teams offer men-tal, sexual and reproductive health care, with a focus on care for survivors of sex-ual violence. In 2017, MSF teams began supporting a local Ministry of Health clinic in Choloma. The facility now pro-vides sexual and reproductive health ser-vices and emergency care.

DEEP SCARSIn parts of Honduras, crime and violence are endemic, and women and girls are particularly affected; an msf clinic offers care and support for survivors

Ruth, a mother of four, fled Honduras with her family last year to escape daily violence. Her husband was kidnapped and released, but their lives were in danger. Their journey has been very difficult, but MSF has been able to help them with medical and mental healthcare.

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Tatiana’s* voice is almost inaudible as she relates what happened to her in Bambari, in Central African

Republic (CAR), three months ago.

“My husband was killed by armed men, and I was taken prisoner. In their camp, the men raped me. I was held there for several days. I lost one of my children there in the camp, and a short while after I managed to send the oth-er child out of the camp to buy some-thing. I finally managed to flee.”

Tatiana’s story is not an isolated one. Since it opened in December 2017, nearly 800 patients have been treated at Doctors Without Borders/Médecins Sans Frontières (MSF)’s sexual violence clinic in the Hôpital Communautaire in Bangui, the country’s capital. Most of the patients visiting the clinic are women, and a quarter of them are un-der the age of 18

Across all of MSF’s projects in CAR, we treated 1,914 survivors of sexual violence in the first six months of 2018 alone, the vast majority of whom were seen in clinics and hospitals in Ban-

gui. This stream of patients provides a glimpse into the huge level of need in a country riven by conflict, and lacking both reliable healthcare and a func-tioning judicial system.

The topic of sexual violence may be rarely broached in public, but Susi Vi-cente, coordinator of MSF’s Sexual Vio-lence Project in Bangui, confirms that there are plenty of prospective patients.

“It’s clear that the number of people who see us only represent the tip of the iceberg. We know that there’s a prob-lem, and that the population needs to know that treatment and help are available. Once people hear that free medical services are available, they are eager to seek treatment.”

RAPE AS WEAPON OF WAR

The widespread use of sexual violence as a weapon of war in CAR has been well documented: in 2017, Human Rights Watch found that armed groups routinely used rape and sexual slavery as a tactic of war over a five-year period between early 2013 and mid-2017.

This recent history bodes ill for civilians currently facing another escalation of violence in the country. In 2018, there were renewed outbreaks of violence in numerous pockets across the country. Bambari, a town previously lauded as a “weapons-free city,” descended once again into conflict last April, giving rise to cases like Tatiana’s.

But though many women experience sexual violence as a direct result of the conflict, it is not the only culprit. While the dangers are greater whenever there is fighting, the general absence of safe-guards and mechanisms to protect those at risk is also responsible, creating a worrying environment for women and children who have little recourse to justice in the event of an attack.

“If someone comes and says that her stepfather is attacking her, or a cousin, there is no system in place that guaran-tees them a safe refuge, and it may be willfully ignored by the victim’s family,” says Vicente. “Many of our cases are re-lated to domestic abuse by a family mem-ber or someone in the community.”

HELP TO RECOVER

The availability of midwives, doctors and psychologists at the MSF clinic enables patients to receive check-ups for both physical and mental health. If a patient arrives within the crucial 72-hour window following an attack, doc-tors are able to prescribe post-exposure prophylaxis, which can prevent HIV infection. Crucially, MSF psychologists can work with patients over the longer term to help them begin to rebuild their lives following a sexual assault.

For Tatiana, life is slowly improving. Now, she is living with her brother and his family and helping her sister-in-law in her daily work. But such severe trauma is not easily forgotten, and the memories simmer just below the surface.

“At the beginning it wasn’t easy for me. Since I started the treatment here, and after talking to the counsellor a lot, I feel a bit better compared to the beginning. But it’s not easy either. It’s not easy at all.”

*Tatiana’s name has been changed for this story to protect her identity.

‘IT’S NOT EASY’In Central African Republic, survivors of rape have few options for treatment and support

WOMEN’S HEALTH: SEXUAL VIOLENCE

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Amandine is a 14-year-old survivor of sexual violence in Central African Republic. After receiving care from MSF, she was able to return to school.

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Three years ago, Fajimatou gave birth to her fourth child. Since then, she had been suffering

from incontinence and regular uri-nary infections. Too embarrassed to raise this problem with the staff at the local health post, she had kept it to herself. When she heard about the listening space for women set up by Doctors Without Borders/Médecins Sans Frontières (MSF) in her village, it was a real relief.

“I knew that there I’d be able to talk to another woman who I could trust. Un-til now we didn’t have a space where we could talk to her freely,” explains Fajimatou.

Fajimatou is far from the only woman to have kept quiet for years. Kolo, 22 years old and a mother of three, ex-plains that she had been in pain since she started having intercourse with her husband, six years ago. “I once plucked up the courage to go to a health centre to see someone, but when I was in front of the health work-er, I was unable to explain.”

Women in Niger still find it difficult to talk about intimate personal issues with strangers, particularly men. This deters them from going to health fa-cilities to ask for help. Therefore, one of the first obstacles for MSF to over-come in the Diffa region in its efforts to improve women’s health was to find a way of encouraging them to seek

advice and medical assistance when faced with problems linked to their sexual and reproductive health, in or-der to avoid sometimes fatal complica-tions. This gave rise to the idea of the listening spaces.

To establish trust with the women and help them to open up, MSF chose to work hand-in-hand with the village midwives. They are the ones who are in contact with the women first. “Having a person who is known and respected in the village inspires more trust in the women than if it were someone from outside the commu-nity,” says Alira Halidou, MSF’s field coordinator in Diffa.

BUILDING TRUST

For the midwives, too, the listening spaces have significantly improved their work and their role in the village. “Be-fore, I supported women during their pregnancies and labour. When MSF re-furbished this space, they also trained me in listening techniques and how to detect signs of vulnerability. Since then, a new bond has developed with the women and they come and ask me for advice more often. As they trust me, they’re also more willing for me to put them in touch with the MSF teams,” ex-plains Dalaran, a local midwife.

This is something Kingui, another mid-wife, has also found. “I’ve been a mid-wife in my village for 10 years now and

women have never come to talk to me as much as they do now. I have young girls aged 15 or 16 who come and knock on my door to ask me questions about their menstrual cycle or their first pregnancy, when they wouldn’t previously have dared to confide in a 50-year-old woman like me. Culturally, it’s a big change.”

Since September 2017, MSF has set up listening spaces in nine villages in the Diffa region. The types of cases that the midwives have been asked to give spe-cial attention to include sexually trans-mitted infections, sexual violence and complications linked to childbirth.

“Niger has the highest fertility rate in the world. In addition, almost 30 per cent of births still take place at home, without medical assistance. This un-derstandably has an impact on the ma-ternal mortality rate, which is also very high,” explains Ann Mumina, MSF’s medical coordinator in Niger.

For some of the women who, out of shame, have been hiding their pain for years, the listening spaces are greatly appreciated. “I’m better since the operation I had thanks to MSF,” says Fajimatou, who was eventually diagnosed with obstetric fistula and underwent surgery. “It’s a great relief for my day-to-day life. Now, I’m the first one to encourage other women from the village to go to the listening spaces to get help.”

COMFORT ZONESIn Niger, many women are reluctant to discuss personal health, so MSF has set up listening spaces where they can speak freely about medical concerns

WOMEN’S HEALTH: ACCESS TO CARE

Fajimatou, MSF patient.

Kolo, MSF patient.

Kingui, midwife.

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YOUR SUPPORT: FAQ

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I PREFER TO GIVE MY SUPPORT AT TIMES OF MY OWN CHOOS-ING. WHY DO I CONTINUE TO RE-CEIVE COMMUNICATIONS FROM MSF SUGGESTING THAT I BECOME A MONTHLY DONOR INSTEAD?

Your donations make it possible for MSF to deliver urgently needed humanitar-ian assistance in close to 70 countries around the world. Last year you helped us provide more than 10 million medi-cal consultations for people affected by disaster, conflict or other life-threaten-ing situations.

When that support comes in monthly and predictable instalments, it means we can plan for the unplannable and be ready to act when emergencies oc-cur — and that we can continue our on-going programs in otherwise neglected areas, caring for people struggling far out of view of the world’s attention.

Sustaining our ongoing operations — which allow us to provide a continuity of care to people who are in precarious situations — while ensuring our capaci-ty to respond requires that we have pre-dictable revenues and resources, and

monthly donations are one of the best ways to support that preparedness.

MSF is a completely independent emer-gency response organization: because we receive more than 95 per cent of all our funding from people like you — from private donors in Canada and around the world, rather than from gov-ernments or large instituions —we are able to go wherever the needs are high-est, according to our own assessments and free from interference or influence by external political, military or econom-ic stakeholders.

That independence is made possible by the generosity of our donors, whose ongoing support gives us the financial flexibility to act quickly and decisively. Thanks to a revenue model founded upon regular and reliable giving, our first response when emergencies occur is to put our teams on the ground im-mediately, rather than to seek the funds we need to act.

If you have any questions or concerns that you would like to raise as a support-er of MSF’s humanitarian medical work, please contact our Donor Relations team in Canada at 1-800-928-8685, or by email at donorrelations@msf.ca.

INCREASING YOUR IMPACT Every year, the generous support of thousands of individual Canadians helps make the lifesaving humanitarian medical work of Doctors Without Borders/Médecins Sans Frontières (MSF) possible. In this section of Dispatches, we consider some of the questions our donors have asked about how MSF works, and about the critical role they play in helping us deliver care to people in need around the world.

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When Dr. Achai Bulabek, a 28-year old physician from South Sudan, started working in a

Doctors Without Borders/Medecins Sans Frontieres (MSF) clinic in the town of Agok, the biggest hospital in the re-gion had just one ultrasound machine. It was located in the maternity ward, and could only be used when a physi-cian with specialized ultrasound train-ing was present.

Doctors in this part of South Sudan did not have access to imaging scans to diagnose patients in critical conditions in other parts of the hospital, such as people with fractures, pulmonary oe-dema or acute abdominal pain. This changed when point-of-care ultra-sound (POCUS) was introduced in the hospital in 2017. Dr. Bulabek and her colleagues received training on how to use the handheld device, which con-sists of a probe that is plugged into a tablet or laptop and can be taken di-rectly to a patient’s bedside. She says that the portable ultrasound has been a game-changer for her and her col-leagues, making it easier and faster to reach a diagnosis and make decisions on how to best treat a patient.

“I was called to perform an ultrasound scan on a small boy of around eight to ten years. He had a history of trauma and abdominal pain for one day,” she

says. “I scanned the boy using our ul-trasound equipment in less than seven minutes. The scan showed free fluid in his abdomen and a ruptured spleen. The decision to undergo a laparotomy and surgery to remove the spleen was made within 15 minutes, at his bedside.” POCUS is just one of 36 transforma-tional projects that are currently being implemented by MSF teams around the globe. In 2016, MSF launched the Transformational Investment Capac-ity (TIC) with the goal of better serv-ing the needs of its patients today, and preparing the organization for the challenges of tomorrow.

“Over the last decade we have wit-nessed the increasing growth of global health and humanitarian challenges in both complexity and scale. They in-clude unprecedented levels of global displacement of people, new patterns of disease outbreaks, and a medical re-search and development system that does not serve the needs of the people MSF assists,” says Emmanuel Guillaud, the head of the TIC Secretariat, which

is based at MSF Canada’s offices in To-ronto and Montreal.

“At the same time, we are seeing tremen-dous technical and medical advances, including artificial intelligence, biotech-nology, hybrid energy and big data, all of which represent unique opportunities to transform MSF’s ability to address the medical and humanitarian needs of vul-nerable populations around the globe.”

Project proposals are submitted by MSF staff members from around the world, and vetted by an international selection committee made up of experts from within and outside the organization. Many of the approved projects are al-ready showing an impact.

One of the largest projects, aimed at in-creasing access to care and treatment for hepatitis C, has had tremendous success during its pilot phase. The project team is testing a new combination of drugs that has shown a 97 per cent cure rate in a recent clinical trial. Other promis-ing projects currently on the go include incubator projects such as the testing of solar-powered air conditioning units and building a migration history tool.

Claudia BlumePress officer, MSF Canada

Deng Kuol Nyanaguek, right, needs an ultrasound, but none is available in this part of South Sudan. A new device makes it possible for MSF medical teams to make better diagnoses even in remote locations. It is part of MSF’s efforts to develop critical tools for challenging contexts.

NEW TOOLS TO SAVE LIVES An MSF initiative based in Canada seeks to improve patient care in places with few resources

HUMANITARIAN INNOVATION

Preparing MSF for the challenges of

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Name: Prudence Motchokoua

Home: Montreal

What is your current field role with MSF? I am the accounting man-ager for the MSF mission in Democratic Republic of Congo, based in Bukavu. It is my first time working with MSF.

What were you doing before joining MSF? My background is in accounting and finance. Most re-cently I was a financial representative for CIBC bank, and I have a degree in finance and accounting from the Uni-versity of Québec at Trois Rivières. Before that I worked as an accountant in Cameroon.

Have you been able to apply your previous professional experience to your work with MSF? Yes, very much, because I’m doing our account-ing, managing transactions and doing many similar things to my previous work. Some of it is different: I had nev-er before worked for a non-profit, and the accounting is not all the same. I am also managing more people. Manag-ing people is not new, but I am doing a lot more than before. And sometimes you are managing people who you also live with, in the same house. So that’s also different!

What has made the biggest im-pression on you? The fact that I can see the impact that we are having in

people’s lives. I work in our office in Bukavu, but I also visit our projects and our hospitals, and meet our pa-tients. It made me understand more what we are doing. When I first began my work, I wondered why we were spending money on providing food. When I went to our projects, I noticed that people lived very far away, and had to walk very far to get care and medicine for their families and their children, and for their babies. It’s not like in Canada, there are not a lot of roads. So then I understood. I had a clear view of what we are doing, and the fact that we are helping people who need assistance is very reward-ing for me.

What led you to apply to work with MSF? In 2010, I was studying in Cameroon. I had a good friend whose family lived on the border with Ni-geria. He went to visit his family, but he never came back. There was lots of conflict and problems in that area. The only organization working in that part of Nigeria was MSF, and so we relied on them for information. I was grateful to them for the help they gave us, but also very impressed with the work they were doing. So I decid-ed that when I completed my school-ing and was able to do so, that I would dedicate at least one year of my life to similar humanitarian work. What’s one piece of advice you would give to someone else from Canada heading overseas with MSF for the first time? They must find their motivation and understand why they want to work for MSF, be-cause it is not easy. They will be away from friends and family. But being motivated will help.

You see first-hand how MSF manages our finances in our field operations. How would you describe it to those of us in Canada who donate in support of MSF’s work? We are so grateful here to all our supporters for what they are doing. I have seen how we spend their money. They should know that every single dollar makes a difference in people’s lives. And I would say thank you.

Prudence Motchokoua’s professional experience helped prepare her for a field role with MSF.

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CANADIANS ON MISSION

‘EVERY SINGLE DOLLAR MAKES A DIFFERENCE’An accountant from montreal sees first-hand the impact of MSF’s work in Democratic republic of congo

Every year, hundreds of Canadians work overseas with Doctors Without Borders/Médecins Sans Frontières (MSF), delivering front-line medical care as part of MSF’s emergency programs. We aim to introduce you to some of them in every issue of Dispatches. For this edition, we spoke with an accountant from Montreal who is helping oversee MSF’s finances in Democratic Republic of Congo.

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Were medical personnel:Doctors, nurses, midwives, specialists

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Were non-medical personnel: Administrators, engineers, logisticians, coordinators

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OF THE 179 CANADIAN FIELD WORKERS AS OF JANUARY 2019:

THEIR HOME PROVINCES ARE:

CANADIANS WORK FOR MSF IN:

COUNTRIES38

Quebec765127184

Ontario

3

Alberta, Saskatchewan & Manitoba

British Columbia

Yukon & Northwest Territories

Nova Scotia, New Brunswick, P.E.I. and Newfoundland & Labrador

CANADIANS ON MISSION

this could be youWE ARE RECRUITING: Administrators, SURGEONS, Water and sanitation experts, PHYSICIANS, Nurses, MIDWIVES, Supply chain specialists, Epidemiologists, Mental health specialists, ANESTHESIOLOGISTS, GYNECOLOGISTS, TECHNICAL LOGISTICIANS, FINANCIAL SPECIALISTS, Pharmacists, HR coordinators, Laboratory specialists, Nutritionists

MSF INFORMATION SESSIONSdoctorswithoutborders.ca/events

Contact us for more informationToll free: 1-800-982-7903 or Email: applications@msf.ca

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Who delivers MSF’s humanitarian medical care?

A t any given moment, there are more than a hundred Canadians working overseas with Doctors Without Borders/Médecins Sans Frontières (MSF), helping provide care to some of the world’s most vulnerable people. They are doctors, nurses, en-gineers, coordinators, administrators, surgeons, logisticians and more, and they are drawn from all parts of Canada by the

urgent humanitarian needs that exist in places affected by conflict, disease, healthcare exclusion or natural disasters.

Without their efforts, MSF would be unable to provide essential care to people in more than 70 different countries around the world. We thank them for their compassion, commitment and dedication.

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CARING FOR THE FUTURE

By remembering Doctors Without Borders/Médecins Sans Frontières Canada in your will, you are making an extraordinary commitment.

Your legacy will help provide medical assistance to people in need, whoever and wherever they may be.

Contact us:legacy@msf.ca

1-800-982-7903 ext. 3630

doctorswithoutborders.ca/mylegacy